By G. Faesul. College of New Rochelle.
You are consulted regarding appropriate eval- uation for occult malignancy buy discount quetiapine 100 mg on-line. Careful history discount 100mg quetiapine with visa, physical examination order quetiapine 100mg without prescription, routine blood counts and chemistries generic 50 mg quetiapine, chest x-ray (CXR), fecal occult blood testing (FOBT), and prostate-specific antigen (PSA); if these are not revealing, no further evaluation is necessary B. Careful history, physical examination, routine blood counts and chemistries, CXR, FOBT, and PSA; if these are not revealing, proceed with colonoscopy C. Careful history, physical examination, routine blood counts and chemistries, CXR, FOBT, and PSA; if these are not revealing, proceed with CT scan of the chest, abdomen, and pelvis D. Careful history, physical examination, routine blood counts and chemistries, CXR, FOBT, and PSA; if these are not revealing, proceed with bone scan Key Concept/Objective: To understand the malignancy workup in a patient presenting with new- onset DVT There is a documented association between malignancy and thrombosis; in a recent prospective trial, patients with idiopathic DVT had an 8% incidence of diagnosis of can- cer in the following 2 years, with an odds ratio of 2. However, it has never been shown that an exhaustive workup for malignancy is cost-effective or beneficial. On the basis of a recent large cohort study, it has been recommended that the evaluation of idiopathic DVT be limited to a careful history, physical examination, CXR, routine blood counts and chemistries, FOBT, and possibly PSA in men and pelvic ultrasound in women. Further stud- ies should be directed by this initial evaluation; if it is unrevealing, then additional tests will not likely help and may produce substantial psychological stress in the patient. A 58-year-old white man presents with weight loss, night sweats, and dyspnea. On examination, the patient appears chronically ill and is pale. Laboratory testing reveals leukocytosis, anemia, and throm- bocytopenia. A bone marrow biopsy with aspirate is performed, and a diagnosis of acute myelogenous leukemia is confirmed. In counseling the patient about chemotherapy, you inform him that he is going to be at increased risk for infections and that a major source of infection will be his own gastrointestinal tract. Which of the following statements regarding the innate immune system and the epithelial barrier in the GI tract is false? Lectins found in secretions bind sugars on pathogens and activate the lectin pathway of complement activation B. Granulocytes marginate in small blood vessels throughout much of the barrier tissues and are available for rapid recruitment to a possible site of infection C. Mucus itself is a protective barrier that traps organisms and debris D. Secretions on the epithelial barrier concentrate complement in such a way that the concentration of complement in secretions is higher than the concentration in plasma E. Monocytes are present in secretions and in most tissues, where they phagocytose unwanted microbes Key Concept/Objective: To understand the basic principles of the innate immune system The innate immune system is particularly active at the interface between the environment and the surfaces of the body that are lined with epithelial cells—namely, the skin and the GI, genitourinary, and sinopulmonary tracts. Intact physical barriers are critically impor- tant for preventing infections. In addition to the epithelial barrier itself, the fluids in these tracts contain mucus, natural antibodies (IgG and IgA), a complement system, and lectins. The complement system in secretions is present at about 10% to 20% of the concentration found in plasma. The lectins in these secretions bind sugars on pathogens and thereby acti- vate the lectin pathway of complement activation. Granulocytes marginate in small blood vessels throughout much of these barrier tissues and are available for rapid recruitment to a possible site of infection. Monocytes/macrophages are also present in secretions and in most tissues, where they phagocytose unwanted microbes. Mucus itself is a protective film that traps organisms and debris; it also contains antibacterial substances. A 26-year-old female patient has had recurrent infections with pyogenic organisms. She has a follow-up appointment with you today to discuss her options.
The patient should be referred to a specialist for definitive diagnosis and treatment order 200mg quetiapine mastercard. On referral buy quetiapine 300 mg on line, diagnostics will likely include CBC order quetiapine 300mg amex, culture of fluid purchase 100mg quetiapine with visa, and computed tomographic (CT) scan to determine the degree of involvement. FOREIGN BODY Any foreign body in the ear canal, such as beads, cotton, insects, or toys, can cause pain. The presence of a foreign body is most common in young children. Pain is often the presenting complaint and may be associated with unilateral, purulent discharge from the canal. Physical findings often include tenderness on manipulation of the ear and with the examination, as well as the foreign body. Depending on the amount of trauma that has been caused by the offend- ing object, the canal may be inflamed, edematous, and have exudate consistent with a resultant OE. Referred Pain A variety of conditions can result in pain that is referred to the ear. Theses include temporomandibular joint pain, dental pain, neck mass/pain, carotodynia, tonsillitis, temporal arteritis, and trigeminal neuralgia. The variety of conditions are beyond the scope of the discussion for ear pain but can be found in other chapters, particularly Chapter 3. In addition to stemming from con- ditions affecting the external and middle ear, otorrhea may indicate leakage of cere- brospinal fluid. Purulent discharge is most often related to an infectious process or a foreign body. Bloody discharge that is associated with recent head trauma may be indicative of a skull fracture. History Immediate proximal causes for ear discharge should be investigated, such as OM with per- foration, OE, mastoiditis, and a foreign body. One should consider more serious condi- tions such as head trauma if an immediate proximal cause is ruled out. Ask about how and when the discharge was first noticed, as well as the patient’s perceived health preceding that event. Explore the possibility of direct or indirect trauma, as well as secondary or compli- cated infections. Obtain a history of previous episodes of ear discharge, as well as of previ- ous ear infections or conditions. A thorough review of systems is warranted, particularly as related to other components of the upper respiratory and neurological systems. Physical Examination Physical examination usually involves the head, ears, nose, and throat. Begin by assessing the patient’s general health and mental status. If there is no history of head trauma and the patient’s general neurological status is intact, proceed to the examination of the ears. Observe both external ears, comparing for symmetry of appearance. Identify areas of inflammation, swelling, deformity, or distortion of landmarks, signs of trauma. Identify the color, odor, and consistency of any discharge that is visible. Palpate the structures of the external ear, noting any tenderness or palpable abnormalities. Observe the distal portion of the canal for swelling, erythema, and discharge, as well as any obvious foreign body. Complete the otoscopic examination, noticing the condition of the canal walls, TM, and visible portion of the middle ear structures. Diagnostic Studies Diagnosis is usually made based on history and physical examination.
The cause is uncertain buy generic quetiapine 100 mg, although there are several theories under consideration buy generic quetiapine 50mg, including nutritional deficit buy quetiapine 200mg overnight delivery, dry mouth generic 200mg quetiapine with amex, and emotional disorders. The patient complains of significant burning pain that may affect the ability to sleep or to focus on normal daily activities. There are no visible clinical signs or abnormalities. The patient should be referred for specialist assessment. DIFFERENTIAL DIAGNOSIS OF CHIEF COMPLAINTS: THROAT Sore Throat or Throat Pain Sore throat is a very frequent complaint in primary care settings. Most episodes of sore throat are associated with self-limited viral upper respiratory infections, although there are a number of more serious causes. In addition to determining the characteristics of the pain, identifying all associated symptoms is helpful in narrowing the differential diagnosis. It is important to identify any other recent illnesses, as well as recent exposures to others who are ill. Determine whether the patient is experiencing any dys- phagia or respiratory difficulty. Physical Examination The physical examination for sore throat should include comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes. A more-thorough neck assessment is indicated if carotidynia or thyroiditis is suspected. Diagnostic Studies Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. Complete blood counts with dif- ferential counts are helpful in determining the cause of sore throat. INFECTIOUS PHARYNGITIS Most cases of pharyngitis are viral in origin, and any number of the respiratory viruses can cause inflammation of the throat. The majority of viral pharyngitis cases are self-limited. Group A beta-hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly referred to as strep throat. Complications of GABHS pharyngitis, although rare, include rheumatic heart dis- ease and glomerulonephritis and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths. Other bacter- ial causes of pharyngitis include mycoplasmal pneumonia, gonorrhea, and diphtheria. Because pharyngitis is most commonly caused by respiratory viruses, the complaints typically include malaise, headache, rhinitis, and/or cough in addition to the throat pain, which can range from mild scratchy discomfort to severe pain. The onset can be sudden, as with influenza, but symptoms may develop over many hours. In all cases of pharyngitis, the pharynx is reddened and tender lymphadenopathy is often present. Depending on the cause, other findings may be present. The findings asso- ciated with varied causes of non-GABHS pharyngitis are summarized in Table 5-3. The classic symptom of GABHS is a severe sore throat, with sudden onset. The patient often also complains of nausea, vomiting, fever, headache, and malaise. Unlike other forms of pharyngitis, the patient does not usually experience rhinitis or cough. The findings of GABHS include very inflamed pharynx, uvula, and tonsils. The tonsils are enlarged, usually with a white or gray-white exudate.
Infections are suspected to be possible environmen- tal triggers buy 100mg quetiapine amex. AS may be triggered by gut infection with Klebsiella bacteria quetiapine 300mg for sale, but the evidence is circum- stantial cheap 100 mg quetiapine with visa, and more convincing proof is needed cheap quetiapine 100 mg amex. Some of the other spondylarthropathies, particu- larly reactive arthritis (Reiter’s syndrome), can be triggered after an episode of bowel infection by bac- teria, or by infections of the genitourinary tract. There is substantial evidence that HLA-B27 has a direct role in enhancing genetic susceptibility to AS. However, having the HLA-B27 gene is not a prerequisite for AS, and people without HLA-B27 can also get the disease. Additional genetic factors may influence disease susceptibility, expression or severity; for instance, genes that are suspected to cause susceptibility to psoriasis, ulcerative colitis and Crohn’s disease, and possibly other genes yet to thefacts 111 AS-16(111-124) 5/29/02 5:55 PM Page 112 Ankylosing spondylitis: the facts be discovered. AS patients have an increased fre- quency of mild gut inflammation, even though they have no intestinal symptoms or any clinically obvious inflammatory bowel disease (IBD). Follow- up studies of such patients indicate that a small percentage of them will develop clinically obvious Crohn’s disease. This suggests that these patients had a sub-clinical form of IBD when they first pre- sented with AS. The presence of this gut inflamma- tion does not show any association with HLA-B27. These findings support the existence of a common link between gut inflammation and AS, indepen- dent of HLA-B27. Similar findings have also been observed in patients with other spondy- loarthropathies. These are cell surface proteins that vary from person to person. Their function is to help the body fight illness by presenting peptides (a few amino acids linked together) derived from foreign proteins (e. HLA are the products of genes located on chromosome number 6; the loci (where the genes are located) are given the letters A, B, C, D, and so on. HLA-B27, or simply B27 for short, is so called because its gene is located at the B locus belonging to the HLA class I group and is assigned the number 27. Many varieties of these 112 thefacts AS-16(111-124) 5/29/02 5:55 PM Page 113 HLA-B27 and the cause of ankylosing spondylitis genes at these various loci exist in the general popu- lation, so it is very difficult to find two unrelated individuals possessing an exactly identical combina- tion of these variations. The presence of the viral peptide antigens with the HLA molecule activates CD8+ cytotoxic T cells specific for that peptide antigen to destroy the infected cell. The role of HLA-B27 in disease predisposition A greater prevalence of AS is observed in HLA- B27-positive first-degree relatives of AS patients than in HLA-B27-positive random controls. This suggests that AS is probably genetically heteroge- neous, i. However, the evidence favors the gene for HLA-B27 being the major genetic susceptibility factor responsible for AS. The more disease-predisposing genes you inherit the more likely you are to suffer from AS, but most likely it still requires some, as yet unknown, environmental (i. Although people who are born with the HLA- B27 gene are more predisposed to AS or one of the related spondyloarthropathies (i. It is important to emphasize that there are far more people in the general population with HLA-B27 who never get AS than those who do. Even in families where one member has the thefacts 113 AS-16(111-124) 5/29/02 5:55 PM Page 114 Ankylosing spondylitis: the facts disease and the HLA-B27 gene, most of their brothers and sisters will remain unaffected even when they have the same gene. Perhaps the HLA-B27-positive person destined to develop spondyloarthropathy may be exposed to certain gut organisms that partially imitate HLA- B27 in ways that lead the bacterial antigens to become immunogenic and somehow trigger the disease. The HLA-B27 protein itself or the peptide bound to and derived from HLA-B27 may have a pathogenic role.
She has had two similar episodes in the past 3 months cheap quetiapine 300mg fast delivery. The pain is located in the epigastrium and radiates to the right shoulder quetiapine 300 mg low price. The patient is also complaining of nausea and vomiting purchase 100 mg quetiapine with amex. At presentation buy discount quetiapine 50 mg online, she says the pain is starting to disappear. On physical exami- nation, the patient has tenderness to palpation in the right upper quadrant. Laboratory testing shows a white cell count of 7,000, a hematocrit of 26%, and a normal platelet count. Her liver function test results are significant only for an indirect bilirubin of 2 mg/dl. Ultrasonography shows three stones in the gall- bladder, no pericholecystic fluid, and no gallbladder wall edema. The patient should be started on antibiotic therapy; in 2 to 3 days, after this acute process resolves, a cholecystectomy should be per- formed B. The patient has acute viral hepatitis; the gallstones are an incidental finding C. If the patient undergoes a cholecystectomy, an analysis of the gall- stones is likely to show black pigment stones D. An endoscopic retrograde cholangiopancreatography (ERCP) should be done, because it is likely that a stone has passed to the common bile duct and is now causing obstruction Key Concept/Objective: To understand the processes that lead to the formation of gallstones Two principal types of stone, the cholesterol stone and the pigment stone, form in the gall- bladder and biliary tract. The cholesterol stone is composed mainly of cholesterol (> 50% of the stone) and comprises multiple layers of cholesterol crystals and mucin glycopro- teins. The pigment stones contain a vari- ety of organic and inorganic components, including calcium bilirubinate (40% to 50% of dry weight). Black pigment stones are most often seen in patients with cirrhosis or hemolytic anemia and are found predominantly in the gallbladder. This patient likely has biliary colic secondary to gallstones. Her laboratory results show evidence of hemolysis (low hematocrit, increased indirect bilirubin). Acute cholecystitis is unlikely in this clini- cal scenario because the pain is starting to disappear after 3 hours, there is no fever, and there is no evidence of leukocytosis on complete blood count. Also, ultrasonography did not show evidence of acute cholecystitis, such as the presence of pericholecystic fluid or edema of the gallbladder. Acute viral hepatitis can present as right upper quadrant pain; however, it is unlikely in this case because the pain is acute and is starting to resolve, and the only abnormal liver function test result is the indirect bilirubin value, suggesting hemolysis. An ERCP is not indicated because there is no evidence of obstruction or cholestasis, such as an elevation in the direct bilirubin level or the alkaline phosphatase level or a finding of a dilated common bile duct on ultrasound. You are asked to consult regarding a 52-year-old man with fever who is in the surgical intensive care unit. The patient has been in the hospital for 6 weeks after being injured in a car accident. He had a cranial fracture and multiple rib fractures; three feet of his jejunum were surgically removed, and he has had multiple complications since then, including pneumonia, sinusitis, and coagulase-negative Staphylococcus bacteremia. All of these complications seem to have resolved with adequate treatment. Over the past 2 days, he has developed increasing fever. He is still intubated and on total parenteral nutri- tion. On physical examination, the patient’s temperature is 102° F (38. The patient has jaundice, and there is tenderness in the right upper quadrant. The examination is otherwise unchanged from previous notes in the chart.